Craniocervical arterial dissections as sequelae of chiropractic manipulation: patterns of injury and management.

OBJECT: Chiropractic manipulation of the cervical spine is a known cause of craniocervical arterial dissections. In this paper, the authors describe the patterns of arterial injury after chiropractic manipulation and their management in the modern endovascular era. METHODS: A prospectively maintained endovascular database was reviewed to identify patients presenting with craniocervical arterial dissections after chiropractic manipulation. Factors assessed included time to symptomatic presentation, location of the injured arterial segment, neurological symptoms, endovascular treatment, surgical treatment, clinical outcome, and radiographic follow-up. RESULTS: Thirteen patients (8 women and 5 men, mean age 44 years, range 30-73 years) presented with neurological deficits, head and neck pain, or both, typically within hours or days of chiropractic manipulation. Arterial dissections were identified along the entire course of the vertebral artery, including the origin through the V(4) segment. Three patients had vertebral artery dissections that continued rostrally to involve the basilar artery. Two patients had dissections of the internal carotid artery (ICA): 1 involved the cervical ICA and 1 involved the petrocavernous ICA. Stenting was performed in 5 cases, and thrombolysis of the basilar artery was performed in 1 case. Three patients underwent emergency cerebellar decompression because of impending herniation. Six patients were treated with medication alone, including either anticoagulation or antiplatelet therapy. Clinical follow-up was obtained in all patients (mean 19 months). Three patients had permanent neurological deficits, and 1 died of a massive cerebellar stroke. The remaining 9 patients recovered completely. Of the 12 patients who survived, radiographic follow-up was obtained in all but 1 of the most recently treated patients (mean 12 months). All stents were widely patent at follow-up. CONCLUSIONS: Chiropractic manipulation of the cervical spine can produce dissections involving the cervical and cranial segments of the vertebral and carotid arteries. These injuries can be severe, requiring endovascular stenting and cranial surgery. In this patient series, a significant percentage (31%, 4/13) of patients were left permanently disabled or died as a result of their arterial injuries.

[The implications of cervical spine degenerative and traumatic diseases in the pathogenesis of cervical vertigo and hearing loss]. / Implicatiile bolilor degenerative si traumatice ale coloanei cervicale in geneza vertijului cervical si a hipoacuziei.

AIM: Cervical spine together with vestibular system,visual system and proprioceptive afferents plays an important role in mentaining balance. Spine damage causes distortions in transmitting informations to the brain,favoring vertigo. MATERIAL AND METHOD: The authors point out the occurrence of positional vertigo on 23 patients (20 patients with cervical spondylosis and 3 patients with cervical spine injury) due to blood flow disturbance through vertebral artery. RESULTS: The mechano-receptors located in intervertebral disks and cervical spine muscles are activated by column movement. Changes of blood flow in the vertebral and basilar arteries are showed up by cervical X-Rays, intracranial Doppler ultrasound or angio-MRI, an audiogram marking out the degree of hearing loss or tinnitus occurence. ENT complex treatment outcomes are analyzed and balneo-physio-therapy performed in order to improve vertigo and hearing loss. CONCLUSIONS: Stress beside muscle overload and cervical spine injures causes alteration in the ear blood-flow circulation that leads to hearing loss, vertigo and tinnitus. It emphasies the need for collaboration between balneologist and ENT specialist in solving balance and hearing disorders with cervicogenic cause.

The role of transcranial Doppler sonography in the identification of patients at risk of cerebral and brainstem ischemia.

OBJECTIVE: To review the literature pertaining to transcranial Doppler (TCD) examination of the anterior and posterior cerebral circulation. This paper focuses on the application of TCD as a screening modality for vertebral artery-induced brainstem ischemic events. DATA SOURCES: A Medline literature search was performed. Key terms included; transcranial Doppler, vertebral artery dissection, neck trauma, stroke and vertebrobasilar system. DATA EXTRACTION: The studies examined TCD techniques that monitor the hemodynamics of the circle of Willis. Papers pertaining to vertebral artery trauma and resulting brainstem injury were included. The validity and reproducibility of these procedures were also reviewed. CONCLUSION: TCD procedures provide hemodynamic data pertaining to intra-arterial vertebrobasilar stenosis and extra-arterial mechanical compression of the vertebral arteries. During cervical spine positional testing, brainstem symptoms may be correlated with TCD documented perfusion deficits. TCD increases the sensitivity of the standard positional test.

[Dissections of the vertebral artery following cervical chiropractic manipulations]. / Dissektionen der Arteria vertebralis nach zervikalen chiropraktischen Manipulationen.

In a 37-year-old female patient complaining of increasing pain in the neck and occiput, chiropractic manipulations at the cervical vertebral column were associated with ischaemias of the brain stem presenting as vertigo, transient "locked-in" syndrome followed by vomiting, and sensorimotor hemiparesis. Digital subtraction angiography (DSA) revealed complete obstruction of the right and slight dissection of the left vertebral artery. The symptoms receded within a few days after heparinisation with 1000 IU/h intravenously. A 39-year-old female patient developed vertigo, nystagmus, tetraparesis and dysarthria two days after chiropractic intervention because of refractory pain in the neck and occiput. DSA showed embolism of the basilar artery and extensive dissections of the vertebral arteries. The basilar artery was completely recanalized after local intraarterial fibrinolysis with 50,000 IU urokinase. During the further course of treatment the symptoms receded under heparin and phenprocoumon over a period of 8 months, except for hemiparesis on the left side especially affecting the arm. Trivial traumas can result in dissections of the vertebral arteries. Severe neck pain is a frequent, typical early symptom. Hence, patients with cervical vertebral column syndromes should receive chiropractic treatment only after careful diagnosis.

Sudden sensorineural hearing loss following manipulation of the cervical spine.

Review of the otolaryngologic literature reveals no reports of sudden sensorineural hearing loss resulting from manipulation of the cervical spine. Indeed, in previously reported cases of vertebrobasilar artery injury following spinal manipulation, hearing loss has received little attention. Two patients with sudden sensorineural hearing loss following cervical spine manipulation are presented. The audiologic findings and cerebral arteriograms are reviewed and treatment is discussed. A review of the anatomy and pathophysiology is also included, and a possible mechanism of injury to the vertebral artery is proposed.

Vertebrobasilar injuries following cervical manipulation.

Four cases of brainstem stroke syndromes followed mechanical cervical manipulation; vascular injury was confirmed angiographically. A comprehensive review of the literature on vertebrobasilar injuries disclosed the various mechanisms of injury and pathogenesis of subsequent vascular complications following cervical manipulation. Emphasis is given to the potentially devastating neurological complications, particularly in view of the increasing utilization of chiropractic therapy.